Are you sure the patient with diabetes knows how to manage being ill?

It can be particularly trying for an individual with diabetes to manage sickness. Illness puts extra stress on the body and increases hormone levels, which in turn cause increased blood glucose (Bg) levels. An increase in medication dosage or additional medications may be necessary when a patient with diabetes is ill.

Patients should monitor blood glucose levels carefully during an illness. If blood glucose is elevated, the patient should test for ketones and NOT STOP taking medication or insulin. Instruct your patients to contact you if they have moderate or large ketones after taking additional insulin, if they have persistent vomiting, or if they are unsure of how to take their medications while ill.

Diabetic ketoacidosis

It is important to discuss diabetic ketoacidosis with type 1 diabetes patients. Diabetic ketoacidosis is a serious complication that occurs when the body produces very high levels of blood acids, called ketones. Diabetic ketoacidosis develops when there is too little insulin in the body. Insulin normally plays a key role in helping regulate sugar (glucose), and is a major source of energy for muscles and other tissues. Without enough insulin, the body begins to break down fat as an alternate fuel. In turn, this process produces toxic acids in the blood stream, called ketones, which may accumulate in the blood and eventually "spill over" into the urine. If left untreated, this may lead to diabetic ketoacidosis. People at highest risk for diabetic ketoacidosis (DKA) include those with type 1 diabetes and those younger than 19 years of age.

The signs and symptoms of diabetic ketoacidosis often develop quickly, sometimes within 24 hours. These include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, loss of appetite, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. More specific signs of diabetic ketoacidosis, which can be detected through home blood and urine testing kits, include high blood sugar levels per a blood glucose meter and high ketone levels in the urine.

Symptoms of diabetic ketoacidosis may mimic those of the flu, so it may be difficult to know whether there is a viral infection or a more serious health problem. If a patient feels ill or stressed, or recently has had an illness or injury, their blood sugar levels should be checked often. Inform patients to contact their health care provider immediately if vomiting and unable to tolerate any food or liquid, if their blood sugar levels are higher than the target range and do not respond to home treatment, or their urine ketone level is moderate or high.

Patients should seek emergency care if their blood sugar levels are consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L), if they have excess ketones in their urine and cannot reach their primary health care provider for advice, or if they have multiple signs and symptoms of diabetic ketoacidosis. Inform patients that untreated diabetic ketoacidosis can be fatal.

Illness can trigger diabetic ketoacidosis. An infection or illness, such as pneumonia or a urinary tract infection, can cause the body to produce certain hormones, such as adrenaline, which may work against insulin. Diabetic ketoacidosis may also result from missed insulin treatments or inadequate insulin therapy, which can cause low levels of insulin. In additon, stress, physical or emotional trauma, a recent surgery, high fever, heart attack, stroke, and alcohol and drug abuse may also lead to diabetic ketoacidosis.

A common complication of diabetic ketoacidosis is low blood sugar (hypoglycemia) levels, caused by insulin allowing sugar to enter the cells. Another complication is low potassium (hypokalemia) levels, due to the fluids and insulin used to treat diabetic ketoacidosis. This can impair the heart, muscles, and nerves. Adjusting the blood sugar levels too quickly can produce swelling in the brain (cerebral edema), which is more common in children, especially those with recently diagnosed diabetes. (For more information, see chapter on Diabetic Ketoacidosis.).

Hyperosmolar coma

It is important to discuss hyperosmolar coma with type 2 diabetes patients. This life-threatening condition requires immediate medical attention. Hyperosmolar nonketotic coma is a complication of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), in which the body tries to get rid of excess blood glucose by passing it through the urine. If left untreated, it can lead to seizures, coma, and death.

Those at risk include older patients, people whose diabetes is poorly monitored, patients with infections, or who have had a heart attack, stroke, kidney failure, or overactive thyroid, people with substance abuse problems, those who have recently undergone an operation, and patients using diuretics, anticonvulsants, steroids, and chemotherapeutic drugs. The following symptoms can occur prior to the onset of coma: Bg >600 mg/dl, dry mouth, warm skin, absence of sweating, fever, leg cramps, confusion, sleepiness, hallucinations, vision loss, frequent urination, or weakness on one side of the body.

Key lab and imaging tests

A health care provider who suspects diabetic ketoacidosis should ask the following questions: "What are your signs and symptoms? When did they first develop? Are they getting worse? Have you been diagnosed with diabetes? Have you recently checked your blood sugar levels? Have you recently checked your ketone levels? Have you lost your appetite? Are you having any trouble breathing? Do you have chest pain? Have you had any illness or infections prior to these symptoms? Have you experienced any stress or trauma recently? Have you used alcohol or recreational drugs prior to these symptoms? How closely have you been following your diabetes treatment plan? How well-managed has your diabetes been during the period prior to these symptoms?"

If diabetic ketoacidosis is suspected, perform a physical exam and various blood tests to determine what triggered the diabetic ketoacidosis and what damage results. Blood tests should measure blood sugar levels, ketone levels, blood acidity (as excess ketones in the blood make it acidic). Additional testing may include blood electrolyte tests, urinalysis, a chest x-ray, and an electrocardiogram.

Diagnosis of hyperosmolar coma is based on vital signs, blood glucose, electrolyte, and kidney function tests, a chest x-ray, urine tests, and EKG.

Management and treatment of disease

If a diagnosis of diabetic ketoacidosis is made, treatment is provided as a three-point approach, in the emergency department or as an inpatient in the hospital. Treatment includes fluid replacement (IV therapy to rehydrate and replace fluids lost through excessive urination and dilute excess glucose in the blood), electrolyte replacement (to ensure proper functioning of heart, muscles, and nerve cells), and insulin therapy through the vein (IV) (to reverse the cause of diabetic ketoacidosis and to ensure the blood is no longer acidic).

Treatment of hyperosmolar coma includes fluid and mineral replacement and insulin therapy through an IV, as well as treatment for the underlying cause of the coma. If infection is suspected, an IV antibiotic will be given. Hyperosmolar coma can be prevented by monitoring blood glucose regularly and managing diabetes and blood glucose levels during periods of illness.

Treatment plan for patients with type 1 diabetes

Take your long-acting insulin, even if you are not eating.

Take your short-acting insulin, to decrease elevated Bg, with food.

Monitor Bg every 2 - 4 hours.

If Bg > 250 mg/dl, check urine for ketones.

If Bg elevated and ketones positive, you need to increase your insulin dosage.

If you are not eating normally, substitute meals for easy-to-digest foods or liquids within the correct CHO count for that time of day.

Drink plenty of fluids.

If nauseated, take 15 grams of CHO hourly. This may be in the form of a popsicle/jello (regular, not sugar free), juice/soda (regular), applesauce, frozen yogurt, or toast.

Dehydration may result from diarrhea. Replace lost fluids with hourly drinks.

If continuous vomiting occurs, seek medical advice because you may rapidly dehydrate.

Treatment plan for patients with type 2 diabetes

Monitor Bg every 4-6 hours.

Continue diabetes medication or insulin. If your Bg are high for 48 hours or more, seek medical advice, as you may need an increase in medication.

If nauseous, take CHO in the form of a popsicle/jello (regular, not sugar free), juice/soda (regular not sugar free), applesauce, fruit juice bar, frozen yogurt, or toast. Glucose is absorbed if taken slowly in small amounts.

Sickness and diarrhea can cause dehydration. It is important to prevent this by replacing lost fluids with hourly drinks.

If continuous vomiting occurs, seek medical advice, as you may rapidly become dehydrated.

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